Right Lower Lobectomy

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CHAPTER 10 Right Lower Lobectomy

Introduction

The bronchial and vascular anatomy of the right lower lobe is consistent, but the level at which these structures branch can vary. Proximal branching may require an alternate approach, and completeness of the fissure between adjacent lobes can greatly influence the surgical approach. The inferior and superior approaches to right lower lobectomy performed as video-assisted thoracic surgery (VATS) are described. The inferior approach involves isolating and transecting the lobar structures from an inferior to superior orientation. Sequentially, the vein, bronchus, and artery to the right lower lobe are transected. This approach reduces dissection in the fissure, which reduces the incidence of postoperative air leak. The superior approach transects the artery, vein, and bronchus. The superior approach is easier when the fissure is complete.

Approach to Video-Assisted Right Lower Lobectomy

Order of Operative Steps

The order of the steps of the operation is as follows: inferior pulmonary ligament takedown, inferior pulmonary vein ligation, right lower lobe bronchus ligation, right lower lobe pulmonary artery ligation, and major fissure completion for the inferior approach. The pulmonary artery is transected first when using the superior approach.

Key Points

♦ The utility incision is placed one intercostal space lower than the standard superior pulmonary vein level to allow better access to the structures in the lower thoracic cavity.

♦ Takedown of the inferior pulmonary ligament makes the lower lobe more mobile for palpation.

♦ The inferior approach avoids fissure dissection and potential air leaks when there is an incomplete fissure.

♦ The superior approach provides early arterial control when there is a complete fissure.

♦ Dissect close to the bronchus to avoid injuring the adjacent pulmonary artery.

♦ Do not compromise the right middle lobe vessels or bronchi when stapling lower lobe structures.

♦ Reinflation before stapling the bronchus can prevent compromise of the remaining airway.

Video-Assisted Right Lower Lobectomy

Step 1. Inferior Pulmonary Ligament Takedown

♦ Exposure: Retract the right lower lobe superiorly through the utility incision.

♦ The thoracoscope is aimed anteriorly with the 30-degree lens pointed posteriorly.

♦ Use electrocautery with an extended tip (or other energy source) to transect the inferior pulmonary ligament (Figure 10-1).

♦ Collect any station 9 inferior pulmonary ligament lymph nodes, and send them to pathology. Lymph nodes should be removed through the utility incision to avoid tumor implantation in smaller incisions.

♦ Electrocautery introduced from incision 1 transects the ligament up to the level of the right inferior pulmonary vein.

♦ Reposition the lung anteriorly, and continue to open the posterior hilar pleura. Remove the lymph nodes posterior and superior to the vein (Figure 10-2).

Figure 10-1 Suction dissects the superior aspect of the inferior pulmonary vein.

Figure 10-2 Dissection using Metzenbaum scissors directed posteriorly on the surface of the pericardium in preparation for removal of the subcarinal lymph nodes.

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